Provider Demographics
NPI:1891451936
Name:SHORTT, AMY NICOLE (ACNP-AG)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:SHORTT
Suffix:
Gender:F
Credentials:ACNP-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 ROSE BUD HWY
Mailing Address - Street 2:
Mailing Address - City:HONAKER
Mailing Address - State:VA
Mailing Address - Zip Code:24260
Mailing Address - Country:US
Mailing Address - Phone:276-873-6300
Mailing Address - Fax:
Practice Address - Street 1:5705 REDBUD HWY
Practice Address - Street 2:
Practice Address - City:HONAKER
Practice Address - State:VA
Practice Address - Zip Code:24260-7436
Practice Address - Country:US
Practice Address - Phone:276-873-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021040583363LA2100X
VA0024190101363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care